Another Day in the Frontal Lobe

Publish Date
Nov 9, 2023
Firlik Katrina
非常诙谐、生动的一本美国神经外科女医生回忆录。主要记载作者7年住院医师培训(residency training)过程的的各种经历和体验。提供了美国(神外)医生培养体系、科室文化方面非常详尽的细节知识。阅读体验很棒。

Chapter 1.

Dead brain tissue (due to “ischemic” stroke) swells. If a large portion of the brain has died, such as in a complete middle cerebral artery stroke, the swelling can be quite impressive, to the point where it causes the brain to shift within the skull, threatening the viability of the remaining normal brain and brain stem.

Chapter 2.

* neurosurgery: neurosurgeons focus on disorders amenable to surgery, which constitute a relatively small subset of all brain-related disorders. * Neurosurgeons are true experts in brain trauma, brain tumors, aneurysms, congenital brain anomalies, hydrocephalus (“water on the brain”), and brain hemorrhages, among other things. All of these problems have at least the option for a surgical solution. * Some diseases can be treated by both a neurologist and a neurosurgeon, like Parkinson’s disease or certain forms of epilepsy. Surgery is usually a last resort. * the majority of neurosurgeons spend the majority of their time operating on spines rather than brains. * neurology * psychiatry. Alzheimer’s disease seems to be on everyone’s mind. Neurosurgeons don’t treat Alzheimer’s disease because no one has ever designed an operation for it. Consider schizophrenia. It affects 1 percent of the population, but, again: no operation for schizophrenia, so no role for neurosurgery. If you ask me about schizophrenia, I can tell you what I learned in medical school a decade ago or, better yet, what I read most recently in The New York Times. I will certainly be conversant, but not an expert. What about these disorders: autism, attention deficit, and Tourette’s? Again, these are not within our surgical scope, but I do find them to be a fascinating read. // 本质上这也是通识教育的目的。

Chapter 3.

Looking back, there was another hint of my father’s dignity as a human being, more clear to me now as an adult: he forbade me from going to the so-called freak shows at the summer county fairs in Ohio. We lived in Shaker Heights, a nice suburb of Cleveland, and we visited these rural fairs to gain an appreciation of a different scenery and culture, and for the greasy funnel cakes with powdered sugar. Although there were plenty of other things to see—livestock, choice vegetable specimens, Amish buggies in the parking lot—I always begged my parents to let me go through the Hall of Human Wonders. At the time, I didn’t understand what was wrong with paying money to see the world’s fattest woman, or the wolf man with excessive facial hair, or the rubber man (who I now know probably had a serious, and potentially life-threatening, connective tissue disorder). Although my father was willing to divulge the true story of Bezoar Boy in the privacy of our dining room, he drew the line at paying to gawk at unfortunate oddities. I do understand the emotions of those who would oppose such use of rodents in medical research, but I am swayed far more by the emotions of a family gathered around the bedside of a stroke victim, wondering why nothing more could be done. As a woman trying to enter a largely male-dominated specialty, what was I supposed to wear to my interviews? I didn’t have many mentors to turn to in this deceivingly trivial dilemma. I had interacted with only a couple female neurosurgeons up to that point. One was exceptionally smart but a bit frumpy, and the other, although also smart, wore higher heels and tighter skirts than I could have managed. And one female neurosurgery resident I knew had a brain tattoo on her hip, before tattoos were commonplace, and I wondered if she used it as proof of her dedication during interviews. (She eventually left neurosurgery to become a radiologist.) Regardless, I wasn’t willing to go that far. // 笑喷

Chapter 5.

Keeping a patient safe depends on the judgment of both the attending and the resident: the attending on knowing how much to trust the resident’s skills and the resident on knowing the limits of those skills. Believe it or not, this very human system is much safer than it sounds. Neurosurgeons are generally intelligent individuals who exercise good judgment (in the OR, at least). As a result, the norm is good patient care and the turning out of a steady stream of well-trained neurosurgeons. When I was a junior resident, after I had performed a history and physical on a patient scheduled to undergo surgery, the woman turned to me with the sweetest voice she could muster and said: “Oh, and by the way, dear, I don’t want any residents involved in my operation.” Although this may seem like a simple request, akin to asking for a private room, such requests were very rarely heeded at our institution. Our chairman, who was to perform the operation, explained to her that the numbers we quote regarding risk and outcomes are based on our tried-and-true routine perfected over the years at our teaching institution. This routine involved a team, and the team included residents. He did not like to deviate from routine. In general, it is wise to avoid deviating from the routine in surgery. Every surgeon can tell you about a mishap that occurred when a VIP was treated differently from everyone else. If avoiding residents is critical to you, a private, nonteaching hospital is always an option. 本章对美国医生年会(annual meeting)的描述真是活灵活现,虽然明面上作者对此并没有太多讽刺。这种由医药企业赞助的年会是美国医疗行业独有的吗?加兰德医生的作品里对这种年会有辛辣的批判(而且好像也是在Chicago!)。

Chapter 6. Routine

“Don’t go into neurosurgery unless there’s absolutely nothing else you could ever see yourself doing.” In other words, unless you’re fanatical about it, it’s not worth the sacrifice. I received this advice from elders in the field, as did other medical students hoping to enter the specialty. For some, the advice triggers introspection, which is the whole point. For others, the gravity of the message and the solemnity of the delivery only enhance the aura of exclusivity surrounding the profession. For those starry-eyed medical students, the thought of joining a tribe of devoted and single- minded practitioners—a tribe that others are not passionate or qualified enough to join—makes the decision even easier. The warning is pure enticement. Neurosurgery is marked by labor-intensive routine sprinkled with brief highs. The highs keep us going, so we hope they aren’t too brief or spaced too far apart. Popular portrayal of surgery on television usually focuses on these highs: saving a life, removing an ugly tumor from an otherwise young healthy brain, separating conjoined twins fused at the head. The laborious routine is far more representative, but not as enticing. (Only a very small handful of neurosurgeons, by the way, have ever separated conjoined twins, including one who wrote a book entitled Gifted Hands, about himself.) Whereas some of the residents do remain principled in their eating and exercise habits (stealing away to what’s known as the “ortho library,” the weight room located in a forlorn corner of the hospital), others tend to pack on extra pounds in concert with the extra stress. Admittedly, I did slack a bit on the exercise, but I endeavored to maintain a reasonable trimness—perhaps, at least partly, inspired by the same “Tall Cool Red One” on the wall that probably should have offended me.

Chapter 7. Evolution through blood

Two competing theories of evolution distinguish themselves by the gradations of change: gradual versus punctuated. According to the more traditional theory, evolution occurs slowly and steadily. The punctuated theory describes an uneven evolution. Based on fossil records, the notion here is that periods of relative stagnation are punctuated by more sudden and dramatic changes, propelling evolution forward at irregular intervals. // 现代无神论者(例如理查德·道金斯)反对突变式的进化这种观点。而倾向于将寒武纪生命大爆发解释为在之前地质年代大部分时期环境和各种条件不适合形成化石岩层。 Through our training, neurosurgery residents evolve from lowly interns to fully fledged neurosurgeons. Based on my own experience, I believe this evolution is both gradual and punctuated. Although the learning curve continues unabated throughout training (and beyond), certain events push the process along at accelerated clips. Bleeding is a simple but pervasive theme in neurosurgery, and one that sheds light on the punctuations in our evolution. There are at least two situations I can think of that constitute informal rites of passage in the training of a neurosurgeon: removing a life-threatening blood clot by yourself and controlling profuse, active bleeding by yourself. The by yourself part is key. The solitary nature of these acts accelerates the evolution of self-confidence above and beyond the comparatively straightforward acquisition of manual skills. It’s one thing to act with confidence when someone is looking over your shoulder and can step in to assist (or bail you out); it’s another to remain confident when no one else is scrubbed in with you. At this point, you may be thinking, “I don’t want any trainees going through this rite of passage when I’m on the table!” but that’s how surgeons come of age, and it’s not as dangerous or as cavalier as it sounds. Our hands have been through all the motions before, and the necessary supervision is always around the corner. Just to remind you, if you come to the ER of a teaching hospital in the middle of the night with a neurosurgical emergency, the resident on call will be the only one immediately available. Senior help can be called in from home, if needed. At nonteaching hospitals, there will be no resident. The staff neurosurgeon will have to be called in, which generally requires that he or she remain within about half an hour from the hospital when covering the ER (hopefully there’s no traffic). So, if you are still squeamish about the concept of the surgeon-trainee, consider the fact that this extra half hour may be unkind to a brain already under duress. I would be grateful for the omnipresent and energetic trainee. The Bat Mitzvah (Bar): is a coming of age ceremony for Jewish boys and girls when they reach the age of 12 or 13. This ceremony marks the time when a boy or girl becomes a Jewish adult. Terry Schiavo case

Chapter 8. Tools

Neurosurgeons are practically worthless without their tools. In order for neurosurgeons to do their job well, these tools need to stay organized. Almost nothing irks a neurosurgeon more than when a surgical instrument can’t be found or handed over quickly enough. This can happen because (1) it is buried in clutter, or (2) the scrub nurse is new. I especially pity the new and disorganized scrub nurse. This fatal combination can bring out the worst in a surgeon. the most commonly used instrument in modern brain and spine surgery, an instrument we deem absolutely essential. We demand two for every case: one for the main surgeon, one for the assistant. The suction (“suction tip”, “sucker”) serves two main purposes: to retract against various tissues, including brain, and to continuously clear the surgical field of fluids that get in the way, namely blood and cerebrospinal fluid. (Hence the omnipresent, somewhat annoying, sound of fluid being sucked through the system, the “sound of neurosurgery.”) The suction tip can also be used to help push things into place, such as when packing various materials into a hole to stop bleeding. The suction, though, has more than just a supporting role. When removing a soft brain tumor, the bulk of the work may be accomplished by the lowly suction, even in this modern era. Other surgeons have been known to make fun of us for our strongly suction-centric ways. (All surgeons use a suction device, but not quite so extensively.) While general surgeons, cardiothoracic surgeons, and orthopedic surgeons toil over abdomens, chests, and limbs, you will notice more cutting, sewing, and tying. In short, they look like they’re doing surgery. Their hand movements are grander. They may even have to get their elbows and shoulders involved for the bigger moves. Neurosurgeons doing brain surgery, on the other hand, tend to look like they are picking at things, sucking things out, little by little, sometimes for many lonely hours at a time. Once the grunt work of bone removal is done and the brain is exposed, the microscope is wheeled into position. The moves are small and delicate. Elbows and shoulders remain still. If the suction is our number-one most basic instrument, the drill may be number two. That’s how we get into the head. Obviously, drilling holes in the head is one thing that distinguishes neurosurgery from the typical desk job. Not so obvious, though, is that the drilling of a hole can be more meaningful than you think. The honor of placing the first “bur hole” of an operation is a gift, of sorts, that we sometimes grant to our eager interns who plan to give themselves over to neurosurgery. We present them with a freshly exposed portion of skull, scalp retracted off to the side, and then ceremonially hand over the weapon. The honor of having drilled into a live human skull then affords the intern bragging rights: “Yeah, I placed a bur hole today. The guy’s fine.” The intern may say something like this, nonchalantly, to his colleagues who are bored stiff from checking labs and writing orders all day. As one of my mentors is fond of saying: “Surgery is controlled trauma.” When you see the device we use for drilling holes, this statement becomes clear. We have a special drill, a “perforator,” that is designed to make this hole-making task foolproof. The drill bit is complex in its geometry and formidable in size. Its function, though, is quite elegant. You have to apply firm and constant downward pressure during the drilling process, but the cutting action stops, miraculously, as soon as you’re through the bone, thereby protecting all that is soft underneath. (That’s why we allow the lowly intern to get a piece of the action—it’s really the drill that we trust.) What you are left with is a nice smooth, round, full-thickness hole in the skull, roughly nickel-sized in diameter. Believe me—this was a great breakthrough in the history of neurosurgery. For all its wonders, though, this drill does have at least one downside. An annoying glitch in the technology makes it nearly impossible to continue using the perforator on the same hole if you stop drilling halfway through. It won’t reengage. Quite disheartening, this is yet another thing that can interrupt the flow of a case, necessitating either chipping away at the remaining bone with a sharp scooping instrument or setting up a different type of drill, with a smaller head, to complete the task. With this glitch in mind, whoever is teaching the intern to use the perforator is tempted to yell “Don’t stop!” above the loud drone of the drill. I have seen, on more than one occasion, the driller stop drilling in order to clarify what is being yelled to him. A favorite teaching point, passed perennially from professor to resident to intern, involves listening to the subtle differences in sound that the drill makes as it passes through the different layers, or “tables,” of the skull. It requires only a couple bur holes’ worth of experience before you can detect, by sound alone, when the drill is about to stop. This is not rocket science, but it is neat. Again, such knowledge distinguishes us from the guy jon the street or at his desk in the office park. Although this may be hard to believe, the following exercise can be a challenge for a neurosurgeon: have a patient lie in front of you, hang the patient’s MRI up on the light box, and point, on the patient’s head, precisely to where the tumor should be located. It’s easy to be off by an inch or even two. Why is this exercise difficult? Mainly because the head is round. // 3-D image-guidance system Before image-guidance systems were available, neurosurgeons would err on the side of using a large incision and creating a generous window into the skull. By maximizing the playing field, they improved their chances of being able to find the tumor. In the modern era, with 3-D image-guidance, the patient’s MRI scan is downloaded into a computer system in the OR, and these images are linked to a navigation wand. When the surgeon touches the wand to the patient’s head at the time of surgery, a pointer appears on the MRI, indicating the precise location of the wand on the head. This allows us to have a kind of X-ray vision. With the guidance of this magic wand, the incision and the bone flap can be centered directly over the tumor, allowing for the smallest possible opening. Once the neurosurgeon starts to remove the tumor, the wand can be used again to point inside the brain, within the tumor, in order to gauge how far he or she has gone. This is helpful in preventing a surgeon from being either too aggressive (going beyond the borders) or not aggressive enough (leaving too much behind). With certain types of tumors, it can be difficult to tell exactly where the tumor ends and the brain begins. The MRI may present these margins more distinctly. A few Luddites in our department pooh-poohed this image-guidance technology at first. They worried that the young ones would come to rely on it so much that we wouldn’t think for ourselves and wouldn’t bother to cultivate the innate 3-D capabilities of our own minds. Their fear may have some truth to it, but patients certainly don’t mind us taking advantage of this technology. The Luddites’ perspective would be similar to preferring a bank teller to add all your deposits with a pencil and paper. While certainly possible, it’s always reassuring to see them use a calculator. // 完全正确。就像研究已经证明Google地图出现严重削弱了现代人大脑的地理定位和导航能力。 Given my sometimes excessive introspection into my own career, I often reflect on the fact that the experience of performing surgery can span the spectrum from pure enjoyment to tedious boredom or even frustration. The most enjoyable cases (for me, at least) involve the greatest number of the following elements: a pleasant, familiar OR team, a “fresh” case (as opposed to a scarred-in “redo”), sharp and well-maintained instruments, a thin patient, glitch-free technology, good music, performance of the case during normal working hours, and a quiet pager. Less enjoyable cases often involve opposite elements. One quickly realizes as a surgeon that only certain elements of the perfect case can be controlled. Given the fact that most surgeons can be classified as control freaks, it can be hard to accept this reality.

Chapter 9. Risk // the handshake AVM patient

AVM(Arteriovenous Malformation):脑动静脉畸形。多为先天性。 a “handshake AVM.” As you walk out of the neurosurgeon’s office, a handshake is all he has to offer. for years, the patient and her parents lived in fear, never knowing if or when this malformation would decide to bleed. They knew that a bleed could be fatal. They also knew that surgery could be fatal. In essence, a decision like this comes down to: Do you want to take your risk up front, all at once (surgery), or slowly, over time (wait and watch)? Individual personality, more than science, can be the driving factor in making such a choice. // 显然,理性的方式是计算和比较两种做法的风险和获益——例如 QALY。然而 QALY 并不能准确衡量特定个体人生的价值。 《Do No Harm》的第2章里 Henry Marsh 叙述了类似的一个(非常精彩的)案例:不相关的检查中无意间发现的一个未破裂的小型(直径7mm)脑动脉瘤(aneurysm)——并且其形状导致无法用介入方式治疗。研究表面这种类型血管瘤每年有0.5%几率破裂(rupture)——后果通常是患者死亡。而手术有4-5%概率失败(患者死亡或严重残疾)——the acute risk of operating was roughly similar to the life-time risk of doing nothing。在那个案例中,患者毫无犹豫地选择了手术——‘I want the op,’ she said. ‘I don’t want to live with this thing in my head,’。Marsh医生主刀的手术最终成功,但过程并非毫无波澜。中途先后换了3个clip(用于封闭动脉瘤的血管夹)——前2个在已经固定在动脉瘤以后才发现是坏的,必须冒着可能撕裂动脉瘤的风险取下来。而最后一个夹子放置过程中移动了2次位置(每次移动夹子都同样有很大风险撕裂动脉瘤)才最终彻底封闭血管瘤。在那章的最后 Marsh 写道: We have been most successful, however, when our patients return to their homes and get on with their lives and never need to see us again. They are grateful, no doubt, but happy to put us and the horror of their illness behind them. Perhaps they never quite realized just how dangerous the operation had been and how lucky they were to have recovered so well. Whereas the surgeon, for a while, has known heaven, having come very close to hell. 然而,那个案例中的概率计算是错误的。对于年轻的病人,假设预期寿命还有50年,每年0.5%的概率相当于 1- 0.995^50 = 23% 的概率一生中会发生动脉瘤破裂——远远高于手术的风险。 本书中这个 handshake AVM 病人手术技术上圆满成功,但病人术后发生了致命的脑大出血。 Despite all good intentions and a technically successful operation, her brain could not tolerate the perturbations in circulation that accompanied removal of the large tangled mass of vessels. Maybe an otherwise normal artery in her brain, not used to the new pressure dynamics, broke open. Or, a critical vein near the malformation may have clotted off, leaving too few outflow options for the brain’s rich blood supply. Whatever the explanation, I imagined that this was the AVM’s final demand for respect, with her scan representing a “Don’t Touch” warning to other surgeons tempted to offer others like her more than just a handshake. It was also a tragic introduction to the mantra I would hear again and again through my training: “The patient is the one taking the risk, not the surgeon.” It’s clear that the brain can accommodate quite nicely to the overbearing presence of a malformation, but can the mind be trained to accommodate just as well? When inaction is the best action, how do you prevent fear itself from becoming an illness? Does the fear simply wear out, or does it have to be forced out? // I doubt NOT. Knowledge is power, but it can also be fear. Surgeons are obligated to educate a patient about their condition and treatment options, but then they are faced with managing the anxiety that goes hand in hand with that knowledge. I have found that handling a patient’s anxiety can be more complicated, and sometimes even more time-consuming, than the surgery itself. Some surgeons loathe this part of the job. It reminds them of all the reasons they didn’t go into, say, psychiatry. They prefer patients under anesthesia to patients wringing their hands, crying, and reading off a list of questions from everyone in their family, including their second cousin. Others find those interactions rewarding. I tend more toward the latter camp, but I do empathize with those in the former because I understand the surgical personality and have just a touch of it myself. if the patient isn’t crying by the time you’re done going over the consent for surgery, then you haven’t done your job. Although I don’t force an upwelling of tears from each and every patient, I agree with the spirit of the advice in that the risks of surgery have to be laid out plain, in the open, and cannot be taken lightly. And even though some patients prefer not to hear all the risks and just want to get the signing over with (worrying that if they hear too much, they’ll change their mind), I think it’s in their best interest to know everything anyway. Some surgeons shun statistics. Others love them. Some patients want exact numbers, others couldn’t care less. The conversations, then, between a surgeon and patient can have many different flavors. In one, you could hear precise percentages and the quoting of recent scientific literature. In another, vague words such as “possible” and “unlikely” would dominate the discussion of risk. Most surgeons are not statisticians, though, and so even when detailed numbers are discussed, they may not be perfectly accurate.

Chapter 10. Emotion

So how can I save myself here? How can I justify tolerating this seemingly depressing job? (I am not a pure altruist and I don’t think anyone is. The desire to “help humanity” can certainly go far, and that is still a primary reason, but there’s got to be something in it for the helper.) Believe it or not, I have experienced at least one personal upside to seeing so much go so wrong. It sounds a bit hackneyed, but I have to admit that I have developed a distinct appreciation for everyday life. For many people, this requires some sort of personal near-death experience. You hear about these revelations all the time, about how someone didn’t appreciate their life until they almost lost it. I’ve been fortunate enough to borrow from everyone else’s experience. I’ve seen people in every state of neurological decline and I’ve seen death, over and over again. And this makes me feel lucky about life, every day. As I think about this, I have to admit that my appreciation for the everyday has become a well-entrenched part of me now. I probably don’t need the constant reinforcement.

Chapter 11. Disturbing Deviations

The most abnormal brain I’ve ever seen belonged to an infant whose external appearance was frighteningly normal. His cute baby look was what made for such a sticky situation: the parents, relatives, and nurses saw a cuddly little boy who sucked on a bottle, cooed, kicked his legs, and even smiled. A basic and somewhat crude underlying fact, though, is that any infant’s sucking, cooing, kicking, and smiling functions (or reflexes) require only the most rudimentary, nonthinking, parts of the human brain, the parts that are roughly similar to those found in much less sophisticated creatures, like reptiles. The overwhelming problem with this infant was that those primitive reptilian parts were the only parts that he had. The more highly evolved regions of the brain—the large cerebral hemispheres —the parts that allow us to develop conscious thought, experience emotion, and communicate with each other (in short, the parts that make us human), were completely absent. A cold, clinical, and involuntary question flashed through my mind on seeing this baby’s scan: Is he really “human”? I kept the question to myself. 积水型无脑畸形(hydranencephaly)又称婴儿性脑积水,指先天性额、颞、顶叶脑质缺如,为巨大的液性空腔替代。 When I walked into the infant’s hospital room for the first time, the lights were off and the shades down, in the middle of the day. The pediatric neurology team was crowded around the crib. The senior neurologist was holding a flashlight up against the baby’s head, and all the residents and medical students stared at the resulting spectacle: a round, pinkish, glowing orb. Because most of the skull was filled with fluid and not brain, and a baby’s scalp and skull are normally relatively thin, the light was able to pass right through, lighting up the head in an eerie display. This “transillumination” diagnostic technique is a very old and simple one, completely antiquated and unnecessary in this age of high-quality CT and MRI scans. Nonetheless, most doctors can’t resist the temptation to try something that they’ve only read about in textbooks, and most doctors will never have the opportunity to examine an infant with hydrancephaly (especially given the ubiquity of prenatal ultrasound), so I probably would have placed the flashlight against the infant’s head, too, if I hadn’t happened to have caught the spectacle secondhand

Chapter 12. Slices // brain (needle) specimen biopsy

As one of my mentors puts it, a brain biopsy is “two scared people separated by a needle.” It involves the scared surgeon inserting a long, thin biopsy needle into the brain lesion of an even more scared patient through the smallest of stab wounds in the scalp and a hole in the skull no wider than a pencil eraser. It’s one of the most minimally invasive forms of brain surgery. Very small lesions, deep within the brain—even within the brain stem—can be sampled with the aid of precise localizing techniques. Luckily, it’s quite rare for something to go wrong—like bad bleeding—but we surgeons tend to worry about the rare. 作者的宗教观——如果必须要选择一个信仰的宗教,那么就选佛教吧。 A key idea in this philosophy(Buddhism) (more a philosophy than a religion, per se, because no god is involved) is that suffering is a natural part of human life, and the only sure way to overcome suffering is to develop control over your own mind. That’s what I like: it puts the locus of control in the individual, the individual mind, and not in any external power. That’s a refreshing concept. You can enjoy the here and now because your thinking is clear, you don’t have to look through the smoke of the mystical, and your mind is not the passive victim of whiplash in the turbulence of external events. The comfort you get from being in charge of your own happiness does not rely on any false hope.

Chapter 13. Fragmentation

Early on in my training, I learned a critical lesson in managing these patients: if a person is not going to make it, and you’re sending him up to the ward for his final hours of existence, you still have to stitch up the bullet wounds in the scalp. Here’s why: death is often precipitated by a buildup of pressure inside the skull. The pressure is due to the sheer volume of damaged, swollen brain tissue. Extreme pressure will eventually lead to one of two fatal events. Either blood flow to the brain will be shut off, or the brain stem—which harbors the control centers for breathing and heart rate—will become compressed and rendered nonfunctional. If the holes in the scalp remain wide open, the swollen brain “pulp” will naturally make its way out through these paths of least resistance, relieving the intracranial pressure, at least temporarily. A normalization of intracranial pressure can delay (doomed) death. // put the family through such prolonged torture.

Chapter 14. Controller Trauma

The forehead is a key zone that we try not to violate, for cosmetic reasons, which forces us to make ridiculously long incisions (sometimes ear to ear) behind the hairline so that we can reflect and fold the forehead forward in order to reach, say, a small tumor just underneath it in the frontal lobe. In special cases, such as for big craniofacial reconstructions in kids, we may collaborate with plastic surgeons. They tend to be even more thoughtful than we are in fashioning a nice scalp incision. For example, rather than cutting across the scalp in a straight line behind the hairline, they may zigzag it all the way, giving it the appearance of having been cut with large pinking shears. When I first saw this, I wondered why they would go to the trouble. It takes longer and is more difficult to close at the end. The attending plastic surgeon responded to my question as if the answer were obvious: What does the kid’s hair look like when he gets out of a pool? If the incision simply goes straight across, the scar may be revealed with the linear parting of the wet hair. With the zigzag approach, the wet hair tends to cover the scar in a more natural pattern, not parting sharply along a dividing line, and the other kids at the pool may not notice it at all. Neurosurgeons don’t think as much about poolside life, but I was touched by the concern, thinking back to my own awkward years as a kid, awkward enough without a large scalp incision and reconstructed cranium underneath. Surgery is trauma, but it’s intelligent, controlled trauma, and it’s done in the patient’s best interest, despite appearances.

Chapter 15. Traces of Thought

Consider an interesting question: What happens to the visual cortex (视觉皮层) of a person who is blind? The visual cortex, a part of the brain in the occipital lobes (in the back of the head), receives visual input from the eyes. That’s how it is stimulated. If there is no visual input, does that area remain completely fallow, nonfunctional, as logic would have you predict? Is it like a solar panel, of one purpose and useless without the sun? They found that the visual cortex in these blind individuals was strongly activated by Braille reading. It was also activated, but less so, by the other tactile tasks that required fine discrimination. It wasn’t activated at all by the simple stimulus of feeling a rough surface. In these normal research subjects, the visual cortex did not “light up” at all, for any of these tasks. In fact, the visual cortex actually showed subtle decreased baseline activity as attention (and blood flow) was shunted to areas of the brain specifically in charge of touch sensations, an area known as the somatosensory cortex, in the front of the parietal lobe. Another study was designed to prove that activation of the visual cortex was critical in blind Braille readers, and not just some sort of an afterthought.3 They used transcranial magnetic stimulation (TMS)—a cool and somewhat sneaky technique that can stimulate the brain via a magnetic force through the scalp and skull—to sort this out. While blind individuals were reading Braille out loud, they placed the TMS device over various parts of the head (with the subjects’ permission, of course). When the TMS device was placed over the occipital lobes specifically, where the visual cortex resides, subjects made a significant number of errors in their reading and would even perceive missing, faded, or extra dots in the Braille text. These studies are a great demonstration of what is called “cross-modal plasticity”—a type of plasticity or flexibility of the human brain in which one part of the cortex can shift its purpose, when necessary, to accept a different type of sensory input. It also m y explain the common observation that people who are blind tend to have certain other heightened sensitivities. With one sensory modality shut down, there is more brain volume available for other sensory functions (hearing, touch, smell). There is similar evidence that the auditory cortex is used for sign language in the deaf. (By the way, TMS has been used in other very interesting ways. An article in The New York Times Magazine described its experimental use in enhancing creativity. A nonartist was asked to draw a dog before, during, and after stimulation, and the differences between the drawings were quite remarkable, with the “stimulated” drawings clearly having more of a lifelike animated feel compared to the unskilled childlike baseline.) There is evidence from brain imaging studies, for example, that the ratio of activation between the right and left frontal lobes (specifically the prefrontal cortex, in front of the motor and premotor areas that control movement) is tied to happiness and a sense of well-being. Too much right- sided activation is associated with a tendency toward depression and anxiety. This ratio goes a long way in explaining the concept of a set point for emotion, different for different individuals, in which we may temporarily swing one way or the other depending on the circumstances (marriage versus divorce), but tend to settle back to our baselines before too long. Richard Davidson, a neuroscientist at the University of Wisconsin, had the chance to study not only nearly a couple hundred regular volunteers, but also a senior Tibetan monk. The monk’s brain activation was the most heavily shifted to the left out of all the other research subjects. With this knowledge as inspiration, non-monk volunteers were taught brain-strengthening meditation techniques similar to those used by Tibetan monks, and were able to shift their ratios over time, concurrently noting that they felt better overall, less prone to being derailed or unraveled by the common annoyances of daily life. 公认的 Happiness 最好的定义是 (emotial) well-being。所以僧侣是世界上最幸福的人。

Chapter 16. Focus // the seizure focus of epilepsy

epilepsy (癫痫): 大脑异常放电。顽固性癫痫(medically refractory epilepsy (not well responsive to medication))治疗方式包括手术切除大脑里异常放电的cortical dysplasia部位 // cortical dysplasia(皮质发育不良)是难治性癫痫的最常见病因 // 通过 EEG (brainwave test) 和 MRI 定位大脑里异常防电位置。 The lesion was obvious to the touch, a hardened knot embedded within soft normal brain // 手术中通过手指触感准确定位癫痫病源位置。 Epilepsy surgery is the purest form of brain surgery. By that I mean that you’re actually operating on the brain itself, not around the brain, underneath it, or through it, as is otherwise often the case. In epilepsy, there’s something wrong with the substance of the brain, usually an area of the cortex, and in surgical candidates we have to try to fix it, by finding and removing the abnormal region. I also like the imaging. Epilepsy surgeons (and their very close allies, epilepsy neurologists) rely on multiple different types of images—MRI, PET (positron emission tomography), SPECT (single photon emission computed tomography)—and try to correlate the imaging findings to every other piece of data, hoping to localize the seizure focus. cold saline on the brain can actually stop a seizure in its tracks—a detail that is probably not common knowledge.

Chapter 17. Chief Concerns // M&M

本章完整描述了神经外科M&M的全程。 The interesting thing is, different residents, drawing from that same collective experience, may come up with different views of the vast array of neurosurgical options by the end of it all. Medicine is a human endeavor. Here’s a secret, then: what happens to you on admission to the ER for a neurosurgical problem may not be based purely (or even mainly) on science. The science regarding a particular situation may well be scant or conflicting. The individual philosophy of the neurosurgeon who happens to be on call that day may be of equal influence. As evidence, M&M conference is chock full of debate, often the same debates over and over again, back and forth, especially the “operate versus don’t operate” variety. You can’t always state a treatment philosophy with absolute certitude (except maybe the one I learned in pediatric neurosurgery: if the mother thinks her child isn’t quite right, then the child isn’t quite right, even if he looks perfectly normal to you). There are so many variables to consider in difficult cases, especially in the older patient: Is the person a frail eighty- five or a hearty eighty-five? What is their baseline quality of life like? Are they demented, and to what degree? What preferences had they expressed ahead of time? What are their family’s wishes? How complicated are the possible interventions? How much “torture” are we willing to put a person through and for what possible outcomes? // 英国心脏外科医生Stephen Westaby的著作《The Knife's Edge》第10章详细生动地叙述了1个案例可以佐证这一点。 I’m thirty-three years old when my chief year ends. Thirty-three. I’ve been in some form of education or training up until this point: college from age eighteen to twenty-two, medical school from twenty-two to twenty-six, neurosurgery residency from twenty-six to thirty-three. My friends who aren’t in medicine have been out in the workplace for years already. I hear about CEOs of Silicon Valley start-ups who are younger than I am. I read the occasional news story about a popular new mayor—my age—elected to office. Hollywood actresses in their thirties are nearing the ends of their careers, which is okay, because they’ve already earned millions. Many professional athletes, at the apex of their professional life, are younger than I am. My parents had a houseful of kids by the time they were my age. I feel as if I have some catching up to do. I hear about other professionals “reinventing” themselves from time to time, trying out a different career, pursuing their intellectual curiosity to various ends, or taking a few months off between jobs to, say, trek in the Himalayas. That type of thing doesn’t go over so well in medicine— particularly surgery—which is often seen as a sort of “calling” and not as amenable to professional wanderlust. Here’s what people would say to a surgeon who wanted to take a look around: “After all those years?” But we reassure ourselves by recalling all the things we’ve experienced that our white-shoe friends in business haven’t, the things that get our hands and shoes dirty and that make a difference in people’s lives. We can always regale in those highs, and look forward to more. At the same time, though, it’s easy to be haunted by the very experiences that most starkly set our job apart.

Chapter 18. Ending // Help patient die with dignity

amyloid bleeds: Cerebral amyloid angiopathy (CAA, 脑淀粉样血管病)引起的自发性脑出血。CAA is characterized by the buildup of amyloid proteins on the walls of brain arteries. The amyloid buildup can lead to fragile blood vessels, which can cause brain bleeds. 最主要的风险因素是年龄。 //衰老会导致脑萎缩(atrophy),头颅内空余空间会增大。所以有时即使发生致命的脑出血导致(不可逆转的)昏迷(coma),颅内压仍然平稳,脑干机能可以很长时期保持正常。——简单的说已经脑死的病人迟迟不死(指通常意义的死亡——自主呼吸、心跳停止) I had seen such things before, and it can be horrifying: an elderly patient sent to the floor for what is thought to be their final hours, and the hours turn into days. The patient gasps and sputters with irregular breathing (giving the appearance of distress), foul odors collect in their mouth and throughout the room, a pneumonia and a bad urinary tract infection set in, no one wants to hold vigil by the bedside, family members visit less frequently, and when they do they prefer to mill around in the hallway. I wasn’t going to let that happen. I swear, sometimes we treat our dying pets more humanely. 这种情况下的人道做法:静脉滴注吗啡(morphine),逐渐增大剂量,使病人自主呼吸渐渐缓慢(slower)和变浅(shallower),最终停止。加速病人自然死亡进程,减轻病人和家属的痛苦。

Chapter 19. Confronting Age

Most neurosurgeons, however (except the selected ones in academia who specialize, for example, only in brain tumors), spend most of their time in an endless quest to treat a growing epidemic: the aging spine. The official term for this very common entity is “degenerative spine disease.” Various studies have suggested that a patient’s actual clinical recovery can be partly tied to whether or not they are receiving disability payments, with payments being associated with slower and less complete recovery. Surgeons talk about this phenomenon among themselves and take it to be self-evident. On the other hand, patients who work for themselves, have a job they love, or have no access to disability payments tend to recover more quickly and more fully. Normal pressure hydrocephalus (NPH) is a brain disorder that occurs when excess cerebrospinal fluid (CSF) builds up in the brain's ventricles. This fluid buildup can press on the brain, causing dementia-like symptoms. // 一种可以被 "Shunt" 神经外科手术治愈的痴呆。

Chapter 20. Brainlifts

transcranial magnetic stimulation // 经颅磁刺激 利用磁场刺激大脑神经细胞 治疗强迫症(OCD)、偏头痛、抑郁症、提高记忆力... Brainlift 手术:在大脑里放置一个电刺激器。相当于永久的 TMS We map out your memory network based on functional MRI—that’s completely painless, of course. Then we take you to the OR and you’re put under general anesthesia. I work with only the best anesthesiologists. We make a small incision—half an inch—in the scalp overlying each major node in the memory network, create a small hole in the skull, and insert a neat little metal plug, similar to a watch battery, that contains both a stimulator-electrode and battery. We close everything up with fine absorbable sutures, and that’s it. It’s nearly impossible for anyone to tell that you even had surgery.” // 电池续航2-3年,可经头皮体外充电